What Are the Differences Between Pre-Authorization & Pre-Certification?
In today’s world of healthcare, it is easy to get overwhelmed with the number of coverage options available and what goes along with each of them. This is especially true when addressing the differences between pre-authorization and pre-certification. These two practices were implemented in an attempt to decrease unnecessary spending. Getting the payer to agree that certain medical services are necessary before paying a claim enforces this.
What is Pre-Authorization?
Pre-authorization is the process that occurs when an insurance company refuses to cover a service unless the provider receives permission to offer you this service. This approval is required for a number of reasons, the main one being that the payers want to avoid unnecessary care and costs.
What is Pre-Certification?
Alternatively, pre-certification is a more specific requirement. This entails a payer needing to review whether the proposed service is medically necessary, or not. If the procedure is deemed necessary, a claim number must be provided as proof before a claim can be paid. This is usually the case for patients taking part in elective surgeries.
The Approval Process for Each
Why Are Both Necessary?
Although some have differing opinions regarding these two practices, it is clear that they are both necessary for varying reasons. When it comes to pre-authorization, insurance companies are just trying to fulfill their duty of deflating out-of-control medical costs. It has been deemed necessary due to the countless circumstances involving care that really is inappropriate.